An estimated 1 billion people worldwide suffer from migraines, which can cause nausea, severe pain, and sensitivity to light and noise. But despite the high incidence of the disease, patients who have frequent headaches and usually take two drugs – one for prevention and one for acute illness – often have to try several different drugs before they find something that works.
This difficulty, and new treatments that have the potential to address both acute and preventive therapy for migraines, were the subject of an editorial published last month in the Journal of the American Medical Association by Melissa Rayhill, Clinical Assistant Professor of Neurology and Medical Specialist for Adult Neurology, published program director at the Jacobs School of Medicine and Biomedical Sciences at UB, and Rebecca Burch, Assistant Professor of Neurology at Brigham and Women’s Hospital and Harvard Medical School.
“The past few years have been revolutionary for headache medicine with the number of treatment advances,” says Rayhill, who treats patients at UBMD Neurology.
“Despite the growing number of therapy options, there are still far too many patients who have not yet found a treatment that is effective for them.”
She says that many patients are not offered effective, migraine-specific therapy, although many are available. “Also, many patients don’t seek treatment because they have a misunderstanding about why they might have a headache in the first place,” she says.
But things are changing quickly when it comes to treating migraines. “There are now so many good, migraine-specific acute treatment options,” she says. “For some patients, finding something effective can take months or longer. Many will find a safe and effective acute treatment for their migraine headaches after just one visit to their doctor, although it can usually take several drug attempts over several weeks to find a good fit. “
While the traditional approach to treating chronic migraines has been to prescribe two drugs – one that works prophylactically and another that works for acute episodes – this approach is changing. “In our editorial, we highlighted some recent studies that show some new treatments are blurring the lines between acute and preventive migraine management,” said Rayhill. “Recently, acute therapy has been shown to be effective in headache prevention when given orally every other day, and intravenous preventive therapy has also been shown to be effective in the acute management of headache. This new approach turns our previous ideas about migraine treatment completely upside down. “
In their editorial, Rayhill and Burch discussed a recent study on eptinezumab that was published in the same issue.
“Eptinezumab is an intravenous therapy that is approved for preventive treatment and given in an infusion center or given by a visiting nurse at home,” explains Rayhill. “The study suggests that it could also be helpful for acute therapy, although logistical and cost considerations may currently rule out a more routine application of this approach in practice.”
She adds that the other subcutaneously administered drugs of the same class (monoclonal antibodies against the calcitonin gene-related peptide, CGRP, a migraine signaling molecule) have not been explicitly investigated in large studies for acute therapy and that these other drugs are in clinical practice usually took weeks to months to see an effect in most patients.
Another treatment that she says could blur the lines between acute and preventive migraine treatment is rimegepant, a low molecular weight, direct CGRP antagonist.
“Rimegepant was recently approved by the Food and Drug Administration for the preventive treatment of migraines, after it was originally approved for the treatment of acute migraines in early 2020,” says Rayhill, adding that most acute therapies for migraines are judged by whether they are Pain and associated symptoms alleviate within two hours of taking the drug. In a recent study, rimegepant was also effective in reducing the frequency of headaches (preventing headaches) when given every other day.
While it usually takes time to find the right migraine medication, Rayhill notes that the outlook for patients definitely improves. “I’ve seen some dramatic responses to many of our existing conventional drugs for both acute and preventive therapy.
“The newer therapies with monoclonal CGRP antibodies (the intravenous therapy, eptinezumab, and the other three subcutaneously administered drugs in the class) and the low molecular weight CGRP antagonists (the oral drugs Rimegepant and Ubrogepant) have produced similarly dramatic responses in my clinical practice.” She continues.
“It is important to note that these reactions are very individual and unfortunately some do not respond to any of the therapies mentioned above. However, I think that both classes of CGRP therapies shine in their improved tolerability – in other words, the reduction in reported side effects compared to other conventional therapies. “
Unfortunately, she warns, cost remains a major barrier to access to CGRP therapies for many, and insurers are often reluctant to adopt them without clinicians and patients going through a number of hurdles.
“Migraine is a disabling neurological condition that patients inherit and there is currently no cure,” says Rayhill. “But with the number of effective treatments, the future is brighter than ever for patients suffering from migraines. Amazingly, there are even more migraine therapies in the pipeline.
“Patients with migraines should expect their treating physicians to be familiar with and comfortable with several acute treatment options, ”she concludes. “Help is within reach”